Trigeminal neuralgia

Trigeminal Neuralgia

Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain.

Treatment of Trigeminal Neuralgia

Lets talk about Treatment of Trigeminal Neuralgia. There are three option of treatment, such as medicines, surgery and complementary approaches. Treatment of trigeminal neuralgia usually starts with medications. However, over time, some people with the condition may stop responding to medications. Gradually patient can get severe shooting pain, burning sensation. In this circumstance, surgery is the only options.

Surgery for Trigeminal Neuralgia

Surgical interventions are divided into Ablative (destructive) and Nonablative (nondestructive) procedures.

Nonablative procedures

Posterior Fossa Exploration, Microvascular decompression (MVD)

Posterior Fossa Exploration: Microvascular Decompression and Partial Sensory Rhizotomy Exploration of the trigeminal root in the posterior fossa is a major operation with a 0.2–0.5% risk for mortality and major morbidity. By a retrosigmoid posterior fossa approach, in which a blood vessel in contact with the trigeminal nerve is dissected free and prevented from re-impinging on the nerve by placing a Teflon pad between the two structures or by transposing the vessel to a different position. This operation preserves the anatomical integrity of the trigeminal nerve, as well as its function in most cases. Posterior fossa microsurgery, whether performed by microvascular decompression (MVD) or partial sensory rhizotomy, is the most effective treatment of typical TN and has provided complete pain relief in 73% of patients at 5 years

Peripheral nerve stimulation

Motor cortex stimulation

Ablative procedures

Lesioning (chemical, thermal, or mechanical destruction of the trigeminal nerve)

 Radiofrequency Ablation/Thermorhizotomy

Thermal lesioning damages nerve fibers in a non-selective manner, although mechanosensitive fibers are more resistant to heat. Thus, some degree of gross touch is usually preserved even after extensive radiofrequency damage. Once the position of the needle has been confirmed by either fluoroscopy or the free flow of cerebrospinal fluid (CSF), the stylet is removed and a radiofrequency electrode thermistor is inserted. Patient sedation is lightened while small pulses of energy are passed through the electrode to obtain details of the potential area of anesthesia to be achieved. Hence, patient cooperation during the procedure is usually required. The patient is then more fully anesthetized, and permanent lesions are made with temperatures in the range of 60–90°C and a duration of 30–90 seconds. After the first lesion is made, further lesioning is usually painless and can be performed with the patient fully awake. The facial sensation is evaluated after each round of lesioning. Lesions are repeated until dense, but not complete sensory loss is achieved in the desired trigeminal nerve divisions. Based on current evidence, radiofrequency thermorhizotomy (RFT) is the most effective percutaneous technique in terms of pain relief, both in the short and the long term.

Balloon Compression Rhizolysis

(Percutaneous Balloon Microcompression)

In this procedure, the trigeminal nerve is compressed with a small balloon to induce ischemic damage on the rootlets and ganglion cells. Once an entry has

been gained to the Gasserian ganglion, a Fogarty embolectomy catheter is inserted through the needle and inflated with nonionic, water-soluble contrast dye until the balloon become pear-shaped. The length of time for inflation varies. Despite insufficient quality data on this technique, the results appear to be comparable to those after RFT.

However, transient masseter weakness affects virtually all patients treated with this technique, and vascular injury and aseptic meningitis appear to be more common than with other ablative techniques.

Glycerol Rhizotomy 

Glycerol is a mild neurotoxic substance that has a slow, nonselective neurolytic effect as it diffuses around the surface of the nerve. Recurrence rates following glycerol rhizotomy are the highest of all the ablative techniques.

Stereotactic Radiosurgery

SRS delivers a high dose of radiation, usually 70–90 Gy, to a small area (isocenter) of the cisternal portion of the trigeminal nerve. The procedure is carried out under local anesthesia with light intravenous sedation and is typically conducted on an outpatient basis. Same-day MRI is performed to provide accurate stereotactic information about the location of the trigeminal nerve.

Nucleus Caudalis dorsal root entry zone lesioning.

This surgery targets the dorsal root entry zone (DREZ) of the trigeminal nucleus caudalis in the brainstem. It is performed with a radiofrequency electrode producing coagulation along the posterolateral sulcus along the dorsal root entry zone, in the posterior aspect of the craniocervical junction.

The objective of the lesion is to interfere with the transmission of pain stimulus through the secondary neurons in this region. When this pain pathway is blocked with the DREZ procedure, the pain signal cannot reach the brain and decreases the processing of pain.